Advisory AS18/11: Providing clinical information into My Health Record
This advisory describes the minimum requirements healthcare services must take to meet Actions 1.17 and 1.18 of the National Safety and Quality Health Service (NSQHS) Standards.
Advisory details
| Item | Details |
|---|---|
| Advisory number | AS18/11 |
| Version number | 7.0 |
| Publication date | September 2026 |
| Replaces | AS18/11 version 6.0 published in January 2024 |
| Compliance with this advisory | It is mandatory for approved accrediting agencies to implement this advisory. |
| Information in this advisory applies to |
|
| Key relationship | All NSQHS Standards |
| Attachment | Not applicable |
| Notes |
|
| Responsible officer | Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2027 |
Purpose
This advisory describes the minimum requirements healthcare services must take to meet Actions 1.17 and 1.18 of the National Safety and Quality Health Service (NSQHS) Standards.
National Safety and Quality Health Service Standards
Actions 1.17 and 1.18 relate to healthcare services that are using or working towards implementing the My Health Record system.
ACTIONS
Action 1.17 states:
The health service works towards implementing systems that can provide clinical information into the My Health Record system that:
- Are designed to optimise the safety and quality of health care for patients
- Use national patient and provider identifiers
- Use standard national terminologies
Action 1.18 states:
The health service organisation providing clinical information into the My Health Record system has processes that:
- Describe access to the system by the workforce, to comply with legislative requirements
- Maintain the accuracy and completeness of the clinical information the organisation uploads into the system.
Issue
The Health Insurance (Share by Default) Rules 2025
The Health Legislation Amendment (Modernising My Health Record – Sharing by Default) Act 2025 resulted in amendments to the My Health Records Act 2012 and the Health Insurance Act 1973 to establish a framework for key health information to be shared to My Health Record by default.
The My Health Record (Share by Default) Rules 2025 - Federal Register of Legislation (‘Share by Default Rules’) require pathology laboratories and diagnostic imaging providers subject to the Share by Default requirements to upload pathology and diagnostic imaging reports.
From 1 July 2026, Share by Default legislation was enacted, commencing with pathology laboratories and diagnostic imaging providers subject to the Share by Default Rules. This will require pathology and diagnostic imaging reports to be uploaded to My Health Record by default, unless an exception applies or an extension of time has been granted.
The requirements apply to:
- pathology reports authored by, or on behalf of, a pathologist
- diagnostic imaging reports authored by, or on behalf of, a radiologist.
Organisations that prepare pathology or diagnostic imaging reports should:
- check whether services are in scope
- understand when an exception to upload may apply
- upload reports or apply for an extension.
Requirements
My Health Records Rule 2016
The NSQHS Standards complement the requirements set out in Part 5 of the My Health Records Rule 2016 (the Rule). The Rule outlines the requirements for providers contributing to the My Health Record system, to ensure the safety and quality of health care provided to patients. These requirements should be described in organisational policies and procedures.
Healthcare Provider Identifier – Individual (HPI-I)
In relation to the use of national patient and provider identifiers, healthcare services are expected to implement systems that align with the national Healthcare Identifiers (HI) service including:
- collecting and validating patient’s Individual Healthcare Identifier (IHI)
- maintaining and monitoring the use of Healthcare Provider Identifiers for organisations (HPI-Os) and individual providers (HPI-Is).
The Australian Digital Health Agency (the Agency) published Australia’s first national plan to deliver a connected healthcare system; the Connecting Australian Healthcare – National Healthcare Interoperability Plan 2023-2028. The Agency is leading the HPI-I adoption across the country. For further assistance with this adoption contact the Agency for further advice.
Standard national terminologies
Healthcare services are expected to integrate standard national terminologies (for example, SNOMED CT-AU including Australian Medicines Terminology) into their clinical information systems. Utilising the National Clinical Terminology Service (NCTS) is recommended, and the Agency can provide advice on connecting to this service.
NSQHS Standards compliance
To comply with Actions 1.17 and 1.18, healthcare services must:
- have completed a gap analysis and developed an action plan that identifies dates to progress the health service to full compliance with:
- all requirements of Part 5 of the Rule;
- use of national patient and provider identifiers (IHIs, HPI-Os, HPI-Is); and,
- use of standard national terminologies
- implement the action plan, monitor and evaluate compliance with the health service defined timelines
- by 1 July 2026 services providing pathology and diagnostic imaging services must implement systems to comply with the Share by Default Rules, in accordance with the legislation.
Resources are available from the Australian Digital Health Agency’s website and My Health Record website, which provide further information on the My Health Record system (see Attachment 1).
Assessment of actions
During an accreditation assessment, assessors are to:
Evidence
- confirm a gap analysis has been conducted, and an action plan has been developed and implemented
- confirm that routine monitoring and reporting on actions and timeframes is occurring
- review evidence that the health service has a system to monitor and evaluate compliance with Action 1.17 and 1.18.
Rating
- rate Action 1.17 as met, only if the health service demonstrates achievement of the actions documented in their action plan for the relevant year
- rate Action 1.18 as met only if the health service demonstrates embedded processes in accordance with the actions documented in their action plan for the relevant year
- rate Actions 1.17 and 1.18 as not met, where organisations are not monitoring their action plan and not meeting their actions for the relevant year in the documented timeframes.
Where My Health Records system is not in use, services may apply to their accrediting agency for Actions 1.17 and 1.18 to be awarded as Not Applicable, as per AS18/01: Advice on not applicable actions.
Assessment for the ‘share by default’ rules
Health Services required to share by default are to be assessed to Action 1.17 and 1.18, without exemption.
During an assessment, assessors are to:
Rating
- rate Actions 1.17 and 1.18 as met only where there is full compliance with the requirements.
- rate actions 1.17 and 1.17 as not met, where organisations providing pathology and diagnostic imaging services have not implemented a system to meet the Share by Default Rules by July 2026.
Reporting
Where there is evidence of non-compliance with Share by Default Rules, accrediting agencies are required to make a mandatory notification to the Commission via the Digital Health program: ACSQHCdigitalhealth@safetyandquality.gov.au